Medical History

Name

Birth Date

Sex

M F

Address

Telephone

City

State

ZIP Code

The following information is essential for this office to provide dental care in a manner that is compatible with your general health. Your cooperation in providing accurate information is necessary to meet your dental needs safely and efficiently. Incorrect information can be dangerous to your health.

*If the question is not understood, you are not certain of the answer, or have any questions, indicate so in the space provided, and discuss the matter with the doctor.

1. Are you currently under the care of a physician?

Yes No

If yes, for what reason.

2. The name, address, and telephone number of my physician is

3. Date of last exam with the physician

4. Are you taking any medicines, including non-prescription medicines?

Yes No

If yes, please list all.

5. Have you been hospitalized or had a serious illness or operation in the past?

Yes No

If yes, explain.

6. Are you allergic or have reacted adversely to any drugs or medicines?

Yes No

If other, please specify.

7. Do you have or had any of the following diseases or problems?

a) Rheumatic fever, rheumatic heart disease, heart murmur, mitral valve prolapse, congential heart disease?

Yes No

b) Heart trouble, heart attack, stroke, angina, coronary insufficiency, coronary occlusion or irregulart heart beats?

Yes No

c) Heart surgery, a pace maker or artificial heart valve?

Yes No

d) High or low blood pressure?

Yes No

e) Do you have pain in the chest upon exertion?

Yes No

f) Do your ankles swell?

Yes No

g) Breathing difficulty, asthma, emphysema, chronic coughs, pneumonia, tubercolosis or lung disorders?

Yes No

h) Diabetes?

Yes No

i) Hepatitis or other liver disease?

Yes No

j) Kidney diseases, renal dialysis or anticoagulant (blood thinner) therapy?

Yes No

k) Fainting spells, dizziness, nervous disorders, convulsions, or epilepsy?

Yes No

l) Psychiatric or neurological problems?

Yes No

m) Anemia, blood disease (leukemia, hemophilia, purpura), sickle cell disease?

Yes No

n) Veneral disease (syphilis, gonorrhea, genital herpes)?

Yes No

o) HIV infections, ARC, AIDS?

Yes No

p) Thyroid problems?

Yes No

q) Stomach ulcers, arthritis, glaucoma?

Yes No

r) Tumor, abnormal growth, cancer, chemotherapy or radiation treatment?

Yes No

s) Sinus trouble, allergy or hay fever?

Yes No

t) Artificial joint or organ?

Yes No

u) Any other disease or condition not listed above?

Yes No

If so, please specify.

v) Osteoporosis

Yes No

v) Osteopenia

Yes No

8. Have ever taken Fosamax (Alendronate), Boniva (Ibandronate), Reclast Actonel (Risedronate), Aredia (Pamidronate) or any other medications containing Bisphosphonate?

Yes No

9. Do you use tobacco products?

Yes No

What kind?

How much?

10. Do you use recreational drugs?

Yes No

What kind?

How often?

11. Do you consume alcohol?

Yes No

How often?

How much?

WOMEN

1) Are you pregnant?

Yes No

If yes, how many months.

2) Are you nursing?

Yes No

3) Are you taking birth control pills?

Yes No

NOTE: Change in your health status should be reported to the office at the earliest possible time.

To the best of my knowledge foregoing questions have accurately been answered. I hereby authorize 46 DENTAL and its staff to release health information obtained from me and information about my dental treatment to third party payer and/or other health practitioners. I also give my consent for 46 DENTAL and its staff to take x-rays, study models, photographs, or any other diagnostic aid deemed appropriate to make a though diagnosis of my dental condition, to administer local anaesthestics, and perform any and all forms or treatment, medications and therapy that may be indicated. I understand that there are no warranty or guarantee to any result and/or cure.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Relationship (if minor)

Date

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